Hand washing a solution to hospital infections

1. Hand washing a solution to hospital infections Dr.T.V.Rao MD Dr.T.V.Rao MD

2. So Why All the Fuss About Hand Hygiene? • Most common mode of transmission of pathogens is via hands! Dr.T.V.Rao MD

3. Dr. Ignaz Semmelweis postulated He postulated that the students might be carrying the infection from their dissections to birthing mothers. He ordered doctors and medical students to wash their hands with a chlorinated solution before examining women in labour. The mortality rate in his maternity wards eventually dropped to less than one per cent. Dr.T.V.Rao MD

4. In the late 1840's, Dr. Ignaz Semmelweis was an assistant in the maternity wards of a Vienna hospital. There he observed that the mortality rate in a delivery room staffed by medical students was up to three times higher than in a second delivery room staffed by midwives. In fact, women were terrified of the room staffed by the medical students. Semmelweis observed that the students were coming straight from their lessons in the autopsy room to the delivery room. Dr. Ignaz Semmelweis Proved the Hypothesis – Many ignored Dr.T.V.Rao MD

5. Does Hand washing Work?Semmelweis - 1847 Dr.T.V.Rao MD

6. Presence – bacterial counts on hands range from 104 to 106 resident microorganisms-attached to deeper layers of the skin and are more resistant to removal; less likely to be associated with HAIs. transient microorganisms-colonize the superficial layers of skin and amenable to removable; acquired by direct contact with patients or contaminated environment surfaces; frequently associated with HAIs. Hand-borne Microorganisms Dr.T.V.Rao MD

7. At any time, over 1.4 million people worldwide are suffering from infections acquired in health-care facilities In modern health-care facilities in the developed world: 5–10% of patients acquire one or more infections In developing countries the risk of HCAI is 2–20 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25% In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44% Estimated rates of HCAI worldwide Dr.T.V.Rao MD

8. Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene Therefore hand hygiene concerns you! You must perform hand hygiene to: protect the patient against harmful germs carried on your hands or present on his/her own skin protect yourself and the health-care environment from harmful germs Why should you clean your hands? Dr.T.V.Rao MD

9. Hands are the major source of pathogens • Hands are the most common vehicle to transmit health care-associated pathogens • Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps Dr.T.V.Rao MD

10. When hands are visibly dirty, contaminated, or soiled, wash with non-antimicrobial or antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands. Indications for Hand Hygiene Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. Dr.T.V.Rao MD

11. Before: Patient contact Donning gloves when inserting a CVC Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery After: Contact with a patient’s skin Contact with body fluids or excretions, non-intact skin, wound dressings Removing gloves Specific Indications for Hand Hygiene Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. Dr.T.V.Rao MD

12. Efficacy of Hand Hygiene Preparations in Killing Bacteria Better Good Best Antimicrobial soap Plain Soap Alcohol-based handrub Dr.T.V.Rao MD

13. Hand washing with soap and water: 56 minutes Based on seven (60 second) handwashing episodes per hour Alcohol-based handrub: 18 minutes Based on seven (20 second) handrub episodes per hour Time Spent Cleansing Hands:one nurse per 8 hour shift ~ Alcohol-based handrubsreduce time needed for hand disinfection ~ Dr.T.V.Rao MD Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.

14. Handrubs Apply to palm of one hand, rub hands together covering all surfaces until dry Volume: based on manufacturer Handwashing Wet hands with water, apply soap, rub hands together for at least 15 seconds Rinse and dry with disposable towel Use towel to turn off faucet Recommended Hand Hygiene Technique Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. Dr.T.V.Rao MD

15. Use either an antimicrobial soap or alcohol-based handrub Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturer Alcohol-based handrub: follow manufacturer’s recommendations. Before applying, pre-wash hands and forearms with non-antimicrobial soap Surgical Hand Hygiene/Antisepsis Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16. Dr.T.V.Rao MD

16. 5 stages of hand transmission one two three four five Germs present on patient skin and immediate environment surfaces Germ transferonto health-care worker’s hands Germs survive on hands for several minutes Suboptimal or omitted hand cleansing results in hands remaining contaminated Contaminated hands transmit germs via direct contact with patient or patient’s immediate environment Dr.T.V.Rao MD

17. Most frequent sites of infection and their risk factors URINARY TRACT INFECTIONS Urinary catheter Urinary invasive procedures Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes 34% 13% LOWER RESPIRATORY TRACT INFECTIONS Mechanical ventilation Aspiration Nasogastric tube Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency LACK OF HAND HYGIENE Most common sites of health care-associated infection and the risk factors underlying the occurrence of infections SURGICAL SITE INFECTIONS Inadequate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision BLOOD INFECTIONS Vascular catheter Neonatal age Critical careSevere underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision 17% 14% Dr.T.V.Rao MD

18. Hands are visibly dirty or soiled, wash with nonantimicrobial soap and water or antimicrobial soap and water. Category IA If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands in all other clinical situations. IA. Alternatively, wash hands with antimicrobial soap and water. IB Before having direct contact with patients. IB Before donning sterile gloves when inserting a central intravascular catheter. IB Indications for Hand washing and Hand Antisepsis Dr.T.V.Rao MD

19. Decontaminate hands not visibly soiled with handrub/antimicrobial (continued) Before inserting urinary catheter, peripheral vascular catheter, or other invasive device. IB After contact with a patient’s intact skin. IB After contact with body fluids, mucous membrane, nonintact skin or wound dressings, as long as hands are not soiled. IA If moving from a contaminated body site to clean site. II After contact with inanimate objects in vicinity of patient. II After removing gloves. Indications for Hand washing and Hand Antisepsis Dr.T.V.Rao MD

20. Adequate hand washing with water and soap requires 40–60 seconds Average time usually adopted by health-care workers: <10 seconds Alcohol-based hand rubbing: 20–30 seconds Time constraint = major obstacle for hand hygiene Dr.T.V.Rao MD

21. Routine Hand Wash Repeat procedures until hands are clean Dr.T.V.Rao MD

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23. The “My 5 Moments for Hand Hygiene” approach Dr.T.V.Rao MD

24. The impact of HCAI • HCAI can cause: • more serious illness • prolongation of stay in a health-care facility • long-term disability • excess deaths • high additional financial burden • high personal costs on patients and their families Dr.T.V.Rao MD

25. Most frequent sites of infection and their risk factors URINARY TRACT INFECTIONS Urinary catheter Urinary invasive procedures Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes 34% 13% LOWER RESPIRATORY TRACT INFECTIONS Mechanical ventilation Aspiration Nasogastric tube Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency LACK OF HAND HYGIENE Most common sites of health care-associated infection and the risk factors underlying the occurrence of infections SURGICAL SITE INFECTIONS Inadequate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision BLOOD INFECTIONS Vascular catheter Neonatal age Critical careSevere underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision 17% 14% Dr.T.V.Rao MD

26. Why Hand Washing Reduces Diarrheal Diseases • Diarrhoeal diseases kill more than 1.5 million children under five each year but the simple act of hand washing can reduce these diseases by >45%.

27. Many countries worldwide are committed to improve hand hygiene You are part of a global movement! Countries committed in 2005, 2006, 2007 and 2008 Countries planning to commit in 2009 Current status, March 2009 Dr.T.V.Rao MD

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29. Create awareness at several places • Hand washing is likely to be especially important where people congregate (schools, offices), where ill or vulnerable people are concentrated (hospitals, nursing homes), where food is prepared and shared and in homes, especially where there are young children and vulnerable adults.

30. Why Don’t Staff Wash their Hands (Compliance estimated at less than 50%) Dr.T.V.Rao MD

31. Skin irritation Inaccessible hand washing facilities Wearing gloves Too busy Lack of appropriate staff Being a physician (“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381) Why Not? Dr.T.V.Rao MD

32. Working in high-risk areas Lack of hand hygiene promotion Lack of role model Lack of institutional priority Lack of sanction of non-compliers Lack of rewarding of compliers Why Not? Dr.T.V.Rao MD

33. Education Routine observation & feedback Engineering controls Location of hand basins Possible, easy & convenient Alcohol-based hand rubs available Patient education (Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381) Successful Promotion  Dr.T.V.Rao MD

34. Teach them earlier in life Dr.T.V.Rao MD

35. Make all Kids partners in Hand washing Dr.T.V.Rao MD

36. Based on the evidence and recommendations from the WHO Guidelines on Hand Hygiene in Health Care (2009), a number of components make up an effective multimodal strategy for hand hygiene What is the WHO Multimodal Hand Hygiene Improvement Strategy? ONE System change Access to a safe, continuous water supply as well as to soap and towels; readily accessible alcohol-based handrub at the point of care TWO Training / Education Providing regular training to all health-care workers THREE Evaluation and feedback Monitoring hand hygiene practices, infrastructure, perceptions and knowledge, while providing results feedback to health-care workers FOUR Reminders in the workplace Prompting and reminding health-care workers FIVE Institutional safety climate Creating an environment and the perceptions that facilitate awareness-raising about patient safety issues Dr.T.V.Rao MD

37. Validated and standardized prevention strategies have been shown to reduce HCAI At least 50% of HCAI could be prevented Most solutions are simple and not resource-demanding and can be implemented in developed, as well as in transitional and developing countries Prevention of health care-associated infection Dr.T.V.Rao MD

38. Nails Rings Hand creams Cuts & abrasions “Chapping” Skin Problems Hand Care also includes Dr.T.V.Rao MD

39. Old CDC, APIC-nonantimicrobial between most patient contacts, antimicrobial before invasive procedures or caring for high-risk patients New CDC-if hands are not visibly soiled, use an alcohol-based handrub for decontaminating hands in all clinical situations; alternatively, wash hands with antimicrobial soap and water New CDC Hand Hygiene GuidelinesMajor Difference Dr.T.V.Rao MD

40. HCAI places a serious disease burden and significant economic impact on patients and health-care systems Good hand hygiene – the simple task of cleaning hands at the right times and in the right way – saves lives There are 5 Moments for Hand Hygiene in Health Care Global compliance with the My 5 Moments for Hand Hygiene approach is universally sub-optimal <insert name of facility> has implemented an Action Plan to improve hand hygiene and reduce infection Your support and compliance with the initiatives is essential to save lives in our facility Our support to hand washing makes the difference Dr.T.V.Rao MD

41. Sir William Osler on Hand Washing • Soap,Water and Common sense, are still the best Antiseptics. Dr.T.V.Rao MD

42. Inspire your children on hand hygiene Dr.T.V.Rao MD

43. The Global Hand washing Day • The Global Hand washing Day took place for the first time on October 15, 2008, the date appointed by UN General Assembly in accordance with year 2008 as the International Year of Sanitation

44. Global Hand washing Day • Global Hand washing Day is a campaign to motivate and mobilize millions around the world to wash their hands with soap. The campaign is dedicated to raising awareness of hand washing with soap as a key approach to disease prevention. Dr.T.V.Rao MD

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46. Hand washing a Tribute to Dr. Ignaz Semmelweis Dr.T.V.Rao MD

47. For Articles of Interest on microbiology and infectious diseases follow me on Dr.T.V.Rao MD

48. Wish to save more lives with hand washing …… • Visit the SAVE LIVES: Clean Your Hands website at: • www.who.int/gpsc/5may/en/ Dr.T.V.Rao MD

49. Programme created by Dr.T.V.Rao MD for Health care workers in the Developing World Email doctortvrao@gmail.com Dr.T.V.Rao MD